After blunt straddle injury to the perineum, the primary morbidity is anterior urethral stricture . Blunt straddle injury is associated with spongiosal contusion, which makes it more difficult to discern the limits of urethral debridement and define the accurate anatomy of adjacent structures, thus acute or early urethroplastly is not indicated . Clinicians should initially establish prompt urinary drainage in acutely injured patients with straddle injury to the anterior urethra in order to prevent urinary extravasation and infection [2, 5]. Therapeutic options for blunt straddle injury include suprapubic diversion or attempted early endoscopic realignment . Both EAU and AUA recommend suprapubic or urethral catheter placement and delayed treatment for blunt trauma to the anterior urethra because the extent of injury is hard to evaluate . Due to the relatively low incidence of urethral injuries and limited available evidence, there is controversy surrounding the optimal management strategy for blunt straddle injury to the bulbar urethra [2,3,4].
Very few literatures mentioned the success rate of EER for anterior urethral injury. Hadjizacharia et al.  reported eighteen patients with acute urethral injuries who underwent endoscopic realignment attempt. There were 6 cases of patients with bulbar urethral injuries and the successful rate of endoscopic realignment attempt was 50%. In our report, 31 (70.5%) patients successfully underwent EER attempt and 13 (29.5%) failed the procedure mainly due to the severity of their injury, and some of them were stopped because the time limits of flexible cystoscopic manipulation was reached. Many reasons may explain the failure of EER attempt including the degree of the injury and the experience of the surgeon. For those with successful EER attempts, the percentage of patients with partial rupture (13/14, 92.9%) is higher than those with total disruption (18/30, 60.0%). Also, the difference between successful EER attempts and failed ones in term of injured urethral mucosa integrity was statistically significant (P = 0.035).
For better vision during EER, irrigation with pressure is needed, which may increase the chance of infection and cause additional injury to the ruptured urethra along with flexible urethroscopic manipulation during endoscopic realignment . Although we limited the flexible cystoscopic manipulation time, the impact of procedure related injury and perioperative infection should be followed. Early reports by Elgammal MA, et al.  stated that in cases of complete urethral injury with perineal hematoma or extravasation, no attempt at urethral realignment was made. However, our study showed although 10 (23.7%) patients had concomitant perineal hematomas and 9 (20.0%) had scrotal hematomas, only 1 case of perineal abscess developed after EER, which was found during surgical exploration and healed uneventfully with treatment. Possible reasons for our good surgical outcomes include broad-spectrum antibiotic use perioperatively and our adherence to strict time limitations for endoscopic manipulating. Also, 2 cases of postoperative epididymitis were successfully managed with antibiotics. Although infection was one of the major complications of EER in our series, there was no significant negative effect on surgical outcomes of urethroplasty.
There is an assumption that with early urine diversion for total or partial urethral disruption the extent of the acute and chronic inflammatory cascade would be limited and the severity of residual stricture may be mitigated . Also, research suggests that a urethral catheter placed across an injured urethra by primary realignment might augment appropriate urethral healing and subsequently decrease urethral stricture rate . Seo et al.  reported the long-term outcome of primary endoscopic realignment for bulbar urethral injuries and 39.2% patients developed urethral strictures in 89.1 ± 36.6 months after surgery. Elgammal et al.  retrospectively studied the management and outcome in 53 patients with straddle injuries to the bulbar urethra. Strictures occurred in 11 of 31 (35%) patients treated initially with SPC and in 18 of 22 (82%) treated with primary urethral realignment (p < 0.01). Park’s research showed that mean stricture length of patients with blunt straddle injuries to the anterior urethra was significantly longer in men with delayed presentation (2.7 vs. 1.8 cm, p < 0.05) . It may be the prolonged urine extravasation into the spongiosum that leads to more spongiofibrosis and greater stricture length. The results of our report showed that strictures occurred in 24 of 31 (77.4%) patients treated initially with successful attempted EER, and the mean stricture length was 1.8 ± 0.8 (0.5–3.0), which was shorter than those with failed EER. However, there is no statistically significant difference when comparing the length of urethral strictures in patients after successful EER to those with failed EER (P = 0.103). Furthermore, patients with relatively mild injury such as a direct kick to the perineal regions might have more chance to achieve a successful catheterization when performing an attempt of gentle blind urethral catheterization and be followed with a good healing, which are not included in our series. That might explain why the rate of urethral strictures is higher when compared to other studies [3, 11]. Thus, the impact of EER on the healing of the injured bulbar urethra and the development of late urethral stricture should the subject of further investigation.
Controversy remains regarding whether SPC or EER is the better acute management strategy for patients with straddle injuries. Although EER is a minimally invasive treatment for patients with blunt straddle injury in an acute setting and is technically possible to perform in most patients, the stricture formation after EER does not decrease significantly. Indeed, 87.5% (21/24) of patients with stricture formation after successful EER attempt require urethroplasty, which is the same endpoint for patients treated with SPC alone. Conventionally, performing a urethroscopy with an attempt of EER in acute setting is a routine procedure in our center for patients with EER. A suprapubic diversion as the initial management should be recommend for some patients with straddle injury because the rate of urethral stricture formation is still very high even in patients with successful EER whether with partial or total urethral rupture according to the findings of our study. Actually, the acute management of straddle injury is shifting from EER to directly performing suprapubic diversion and waiting for later urethroplasty in our present emergent practice, especially for those with total rupture.
In our series, the endoscopic interventions, including dilation and DVIU, for urethral strictures after EER brought patients with a low success rate, and most of them were successfully managed by urethroplasty instead of dilation or DVIU again. According to the AUA guideline for male urethral stricture, another endoscopic procedure is unlikely to be successful for patients who are previously treated with dilation of DVIU because repeated endoscopic treatment may cause longer strictures and also increase the complexity of subsequent urethroplasty .
This study has several limitations. First, the sample size of 44 is large than most of the prior reports, but may still be small. For example, the lengths of stricture between successful and failed EER may become significant (p = 0.109 in our study) in a study of large size. Second, the follow-up time of 3 years could be longer to reveal the long-term outcome of EER. Finally, this retrospective study may have some selection and recall biases. Additional works are needed to address these limitations.